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09060002�z �O W? 11s Q �z UO V. �- OU CITY OF CUPERTINO PERNIITW ajT �T BUILDING DIVISION 1Lf�k�aTt1�i1 BUILDING ADDRESS: PERMIT NO. OWNER'S NAME: PERMIT ISSUE DATE PHO S A CONTROL NO. 408 966-6541 ARCHITE.CT/ENGiNEER BUILDING PERMIT INFO BLDG ELECT PLUMB MECH LICENSED CONTRACTOR'S DECLARATION Job Description 1 hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing P with Section 7000) of Division 3 of the BusiMs. and Professions Code, and my license is in full force and elf, � DEFERRED SUBMITTAL—TUSS CALCSB (3500SQ) ,ORIG License Class Lie.' Date Contractor 14408100187 NO NEW PERMIT. ARCHITECTS DECI.ARA O I understand my plans shall be used as public records Licensed Professional OWNER -BUILDER DECLARATION I hereby affirm that 1 am exempt from the Contractors License Law for the following reason. (Section 7031.5, Business and Professions Code: Any city or county which requires a permit to convect, alter. improve, demolish, or repair any struaum prior to its issuance, also requires the applicant for such permit to file a signed statement that he is licensed pursuant to the provisions of the Contactors License Law (Chapter 9 Sq. Ft. Floor Area Valuation (commencing with Section 7000) of Division 3 of the Business and Professions Code) or 0 that he Is exempt therefrom and the basis for the alleged exemption. Any violation of APN Number Occupancy Type Section 7031.5 by arty applicant for a permit subjects the applicant to a civil penalty of ME more than five hundred dallara (S500). 35918036 .00 ❑ L as owner of the property, or my employees with wages as their sole compensation. Required Inspections will do the work and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who buUdg or improves thereon, and who does such work himself or through his own employces, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owrer- builder will have the burden of proving that he did not build or improve for purpose of sale.). ❑ L as owner of the property, am exclusively contracting with licensed contactors to construct the project (Sec. 7044, Business and Professions Code:) The Contractors U- ccnse Law does not apply to an owner of property who builds or improves thereon, and , who contracts for such projects with a eonuactor(s) licensed pursuant to the Contractors License Law. ❑ I am exempt under See , B & P C for this reason Owner Date WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a Certificate of Consent to self-Insum for Workcrs Compen- sation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. ❑ I have and will maintain Worker's Compensation Insurance, as required by Section 3700 of the Labor Code, for the performance of Ilse work for which this permit is Issued ' My Workeess Compensation Insurance carrier and Policy number me Carrier. PolicyNo.: I �% t_ �G%9 CERTIFICATE OF EXEMPTION FROM WORKERS COMPENSATION INSURANCE (This section teed not he completed if the permit is for one hundred dollars (SI00) or Icss_) , I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in any manner so as to become subject to the workers' Compertsadon Lawsof California. Date Applicant NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become subject to the Workers Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be doemed revoked. CONSTRUCTION LENDING AGENCY 1 hereby affirm that there Is p construction lending agency for the performance of the work for which this permit is issued (Sec. 3097, Civ. C.) Lenders Name , Lenders Address I certify that 1 have read this application and sate that the above information is correct I agree to comply with all city and county ordinances and sate laws relating to building construction, and hereby suuhorim representatives of this city to cotter upon the above -mentioned property for inspection purposes (We) agree to save, indemnify and keep harmless Ilse City of Cupertino against liabilitica.judgments, costs and expenses which may In any way acme against said City 2�� SOURCE REGULATI -roofs Type of Roof Signature ol'ApplAnAartracitor Date HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future building occupant store or handle hazardous material as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety Code, Section 25532(a)7 All roofs shall be inspected prior to any roofing material being installed. [:3 Yea No � If a roof is installed without first obtaining an inspection, I agree to remove Will the applicant or future building occupant use cqulpmcot a devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection. District? ❑ Yes tgj No - 1 have read the hazardous materials requirements under Chapter 6.95 of the Califor- nia Health & Safely Code, Sections 25505.25533 and 25534.1 understand that if the building does not currency ve letartt, that it is my responsibility to notify the occupant or the requirements whi m 'or to issuance of a Certificae f Occupancy. Signature of Applicant Date � � All roof coverings to be Class'%" or better Owner or au o agent Date '